Polio Place

In mid-August 2016, I bumped my right elbow on the bar of my wheelchair, and it hurt a lot for a few days. But it wasn’t till late September that I developed a bursa. The nurse practitioner at our doctor’s office drained it, but it filled back up. When I went there the following week she didn’t want to drain it again without sending me to an orthopedist.

The next Monday I saw an orthopedist. He took x-rays and could see no fracture. He drained the bursa and told me to wait two weeks. He discussed surgery to remove the bursa but said it would require general anesthesia which I cannot (actually choose not to) have. I use a ventilator at night and have for many, many years.

He prescribed a padded elbow sleeve which helped protect it. I saw him two weeks later; the bursa was back. He drained it again and wrapped it very tight with an ace bandage. However, my husband helped me loosen the bandage after we left the office. It was so painful. The physician was very distant and seemed to prefer not to have me as a patient, or that’s what it seemed like to me.

I am looking for suggestions based on experiences, because I use my elbow a LOT. For example, to put my corset under me in bed; to help get up out of bed; to put my underwear on; to put slacks up and down. My right arm is my WEAK arm, and I can’t lift my it above my armrest. I lean on my right elbow to help me eat.

I would like to know if is there any other treatment besides surgery? I feel I would be bedridden after surgery and would become even weaker than I am now.

Response from Dr. William DeMayo, practicing physiatrist: Sounds like a very difficult situation and especially difficult to answer without seeing her, but here are few thoughts.

• She does not seem to have a lot of trust in this orthopedist and I'm surprised general anesthesia is needed. She may want to get another opinion.
• A therapy referral to see if there are any options to modify the technique she uses for the listed activities to eliminate or minimize pressure on the elbow would be a good idea.
• It sounds counterintuitive but padding the arm over the bursa may increase pressure in that area. A padded arm support that increases pressure below the bursa (onto the forearm might be a consideration).
• I did not see any mention of anti-inflammatories (Medrol or NSAIDS).
• Regular icing can help reduce inflammatory response (I always say, "If regular icing make sense for a million-dollar pitcher coming off the mound, it's worth considering.”)
   

Response from Marny Eulberg, MD, retired family physician: Her treatment to date is very reasonable and conservative and what would normally be done for an olecranon bursitis.

Surgery is sometimes done when multiple draining has not helped (drainage alone, frequently, but not always, solves the problem). I’m not sure why this type of surgery would need to be done under general anesthesia. It seems that various kinds of local/regional blocks could be done to adequately anesthetize the area. She did not mention having the bursa drained and at the same time injected with a steroid which could still be tried.

Most of time this type of problem doesn’t cause much problem for the patient and many just “live with it” for years unless it becomes infected, which they sometimes do. In her case, she rests on her right elbow to eat and the swelling may interfere with her daily functioning.

Response from Dr. Selma Calmes, retired anesthesiologist: It should be possible to do removal of the bursa with a regional anesthesia technique and thus avoid general anesthesia. Modern-trained anesthesiologists are (and should be) competent at various nerve blocks and the use of ultrasound to identify the nerves that need to be blocked.

Regional techniques are increasingly used for even major procedures, because they result in more favorable patient outcomes. In general, university hospitals should be able to care for this patient using regional anesthesia. An academic hospital should also be able to handle her postop ventilator situation and any need for postop pain relief.

Response from Dr. Fred Maynard, retired physiatrist: I have had a fair amount of experience in treating and following people with olecranon bursae, most of whom were people with SCI (paras & quads).

In this case, I think the critical issue is whether it is symptomatic, either painful or interfering with her functional use of the elbow. Given what sounds like a lot of weight bearing use of that elbow, surgery would involve a fairly long period (4-6 weeks) of not weight bearing on the elbow to insure good healing.

That time period of not doing usual activities with weakened post-polio arms can be risky for an older post-polio person, independent of other risks of surgery and the chance that the bursa might reoccur anyway (probably not likely, however).

If it is not symptomatic, I would advise her to "wait it out.” The chance that it may decrease in time on its own is better than the small chance that it could become infected - especially since she has sensation in it, as opposed to people with quadriplegia.

Certainly, if surgery were to be done, a local anesthesia would be preferable and feasible, as Dr. Calmes said, unless we are missing some other information.

Response from polio survivor: I saw a different orthopedist Friday. I liked him 99% better than the first doctor I saw.

He looked at my elbow and we talked. (I told him about PHI). I also showed him the opinions of the physicians and Dr. Maynard's note. He agreed 100%. I'm wearing the padded elbow sleeve which protects it and I have taken a "wait and see" attitude.

Further response from polio survivor: It is mid-November and there is good news...the bursa on my right elbow is gone. It happened last week. My elbow is still somewhat tender, so I've been wearing the padded elbow sleeve but I can use my arm without pain. Amazing but so thankful!!